[Atypical neuroleptics, pharmacology and clinical importance]

Since the development of clozapine the investigation of atypical neuroleptic compounds has become increasingly relevant. Compared with classic neuroleptics they are distinguished by either fewer or absent (clozapine) extrapyramidal side effects, some of them also by lower increases of serum prolactin concentrations. Pharmacologically they are a group of heterogeneous substances. At the level of transmitter systems a high 5HT2/D2-ratio is regarded as the best criterion to distinguish between atypical and classic neuroleptics. Further differences involve: the preferred effects of atypical neuroleptics on mesolimbic D2 receptors compared to striatal dopaminergic neurotransmission; a higher potency of some atypical neuroleptics to antagonize D1-receptors; the increase of serum corticosterone concentrations by some of the atypical neuroleptics.

Erythrocyte membrane phospholipids in psychotic patients

Thin layer chromatography and laser densitometry were used to examine erythrocyte membrane phospholipid composition in 13 medication-free patients with schizophrenia or schizoaffective disorder and 11 healthy control subjects. The patient group had significantly decreased levels of phosphatidylethanolamine and a significant increase in sphingomyelin. The patient group also showed a trend toward decreased levels of phosphatidylinositol bisphosphate. Levels of phosphatidylcholine and lysophosphatidylcholine did not significantly differ between groups. There were no significant effects of age, body mass index, or gender on any of the phospholipid parameters. The observed alterations may point to abnormalities in key membrane-related functions, including signal transduction and ion transport.

The profile of C-reactive proteins in functional psychotic states in a cohort in Nigeria

Based on the findings of previous work involving the measurement of 8 acute-phase proteins in 8 subjects receiving electroconvulsive therapy, we assayed the levels of C-reactive proteins (CRP) in 40 functional psychotic subjects, 37 of whom were consecutive admissions at the psychiatric ward. From 16 subjects, a second sample of blood for assay of CRP was collected 6 weeks after discharge from hospital, when the patients were no longer experiencing psychotic symptoms. The patients and controls were screened for tissue injury, inflammatory conditions and other diseases. We found that 14 (35%) of the psychiatric patients and only one (2%) of 50 normal control subjects had detectable levels of CRP. At follow-up, none of the 7 patients in whom CRP had been earlier detectable had measurable levels of CRP in the non-psychotic state. The presence of CRP was not related to biochemical indexes of nutritional status (total proteins and albumin), nor did clinical variables such as type of psychosis, pacing in acutely disturbed patients, use of intramuscular injections or diet and drugs distinguish the two groups of patients. It is suggested that the presence of CRP in the psychotic state is probably a state-dependent expression of nonspecific humoral immune alteration in subjects in whom more specific tests could reveal some immune alteration.

A familial/genetic study of plasma serine and glycine concentrations

Plasma serine and glycine concentrations were assayed in a sample of 28 nuclear families (n = 108). Complex segregation analysis of these familial data reveals significant genetic control of concentrations via a single major gene locus. The serine and glycine metabolizing enzyme serine hydroxymethyltransferase (SHMT) is suggested as the most likely candidate for this single major gene locus.

Glucocorticoid receptor number and cortisol excretion in mood, anxiety, and psychotic disorders

In the present study, we measured cytosolic lymphocyte glucocorticoid receptor and 24-hour urinary cortisol excretion in patients with major depressive disorder, bipolar mania, posttraumatic stress disorder, panic disorder, and schizophrenia. Patients with major depression had the smallest, and posttraumatic stress disordered patients the largest, mean number of glucocorticoid receptors per cell compared to patients in the other groups. Bipolar manic and panic patients did not differ from each other in regard to the number of lymphocyte glucocorticoid receptors. Bipolar manic and panic patients did have significantly more glucocorticoid receptors/cell than schizophrenic patients. The mean 24-hour urinary cortisol excretion was significantly higher in patients with major depression and bipolar mania than in those in the other diagnostic groups. Lymphocyte glucocorticoid receptor number and cortisol excretion tended to be inversely related, when the entire sample was considered as a whole, but this effect did not reach statistical significance. It is concluded that lymphocyte glucocorticoid receptors may be modulated by multiple influences, not just ambient cortisol levels. These preliminary data suggest that the assessment of lymphocyte glucocorticoid receptor number in tandem with cortisol levels may provide a more meaningful estimate of hypothalamic-pituitary-adrenal axis activity than is achieved using cortisol alone.

Haloperidol response and plasma catecholamines and their metabolites

Eleven acutely psychotic patients with schizophrenia or schizoaffective disorder underwent a 5-7 day drug-washout period (with lorazepam allowed) prior to participating in a 6-week controlled dose haloperidol trial. Patients were evaluated longitudinally with clinical ratings and with plasma measures of the catecholamines dopamine (pDA) and norepinephrine (pNE) and their metabolites, homovanillic acid (pHVA) and 3-methoxy-4-hydroxyphenylglycol (pMHPG). All patients exhibited clinical improvement with haloperidol; the decrease in their Brief Psychiatric Rating Scale (BPRS) scores ranged from 32 to 89%. Measures of pHVA increased within the first week of treatment and returned to baseline by week 5. The pattern of change of pDA resembled that of pHVA. The pattern of change of pNE and pMHPG revealed a decrease over the course of treatment. The early increase and the subsequent decrease in pHVA were strongly correlated with improvement in positive symptoms on the BPRS. These data are consistent with previous reports on the change in pHVA and pMHPG during clinical response to haloperidol. The data on change of pDA and pNE further describe the nature of the biochemical response to this drug.

Hyperdopaminergia in schizophreniform psychosis: a chronobiological study

Circadian rhythm abnormalities have been described in various psychiatric disorders, but they have not received much attention in studies of schizophrenia and schizophreniform psychosis. The present study used the cosine model to determine the circadian patterns of amino acids, dopamine, and prolactin concentrations, which were analyzed over a 24-hour period in serum of healthy subjects, drug-free schizophrenic patients, and neuroleptic-treated schizophrenic patients. The mesor (the daily mean) of phenylalanine was lower in drug-free schizophrenic women than in healthy women. The mesors of the ratio of phenylalanine or tyrosine to competing amino acids were similar in healthy subjects and patients. The ratio of phenylalanine/competing amino acids showed a phase advance (i.e., earlier onset of the time of highest concentration) in drug-free patients compared with healthy subjects. Schizophrenic patients displayed a higher dopamine mesor than healthy subjects. Female drug-free schizophrenic patients had lower prolactin mesors and lower amplitudes (i.e., half of the total predictable change in rhythm) than healthy women. Compared with healthy subjects, schizophrenic patients showed a phase advance of circadian prolactin concentrations. Neuroleptics raised the prolactin mesor and amplitudes but did not elicit any phase change in amino acids, dopamine, or prolactin. These data confirm the indirect pharmacologic evidence of increased dopaminergic activity in schizophrenic patients that relates to dopamine's precursors and to the neuroendocrine regulation of prolactin.

Treatment guidelines for valproate in bipolar and schizoaffective disorders

An increasing number of uncontrolled and controlled studies have shown that the anticonvulsant drug valproate is effective for the acute and prophylactic treatment of some patients with bipolar disorder, including those who respond inadequately to or cannot tolerate treatment with lithium or carbamazepine. Uncontrolled studies suggest that valproate may be effective in some patients with schizoaffective disorder. In this article, studies of the efficacy of valproate for the treatment of bipolar and schizoaffective disorder are briefly reviewed, and clinical guidelines for its use in these patients are presented.

Effects of haloperidol on human plasma magnesium

The effect of haloperidol treatment on human plasma levels of magnesium (Mg), calcium (Ca) and phosphorus (P) was assessed. Haloperidol treatment significantly reduced plasma Mg but not plasma Ca or P levels. This finding contrasts with studies using other neuroleptics where reductions in both Mg and Ca concentrations were observed. The addition of lithium to haloperidol treatment resulted in an elevation of plasma Mg, but not Ca or P, to levels significantly greater than those at baseline. The reduction of Mg levels by haloperidol may reflect the ion's involvement in the pathology of psychosis and/or in the mechanism of generating extrapyramidal side effects.

Relation of plasma and red blood cells reduced haloperidol concentrations to haloperidol reductase activity assayed in red blood cells in psychiatric population

1. Haloperidol (HAL) reductase activity in red blood cells (RBC) was determined by a newly developed assay method in 120 blood samples from 75 Japanese psychiatric patients receiving HAL. 2. Plasma concentrations of HAL and reduced haloperidol (RHAL), a reductive metabolite of haloperidol, were also measured in these samples. 3. RBC concentrations of HAL and RHAL were measured in 62 of these samples. 4. No significant correlations were found between HAL reductase activity in RBC vs plasma or RBC RHAL/HAL ratios, which may represent activity of the enzyme metabolizing HAL into RHAL. 5. RHAL concentrations were three times higher in RBC than in plasma, though HAL concentrations were at the same level in both tissues. This may reflect accumulation of RHAL in RBC.

Acutely psychotic patients receiving high-dose haloperidol therapy

Despite the trend towards lower neuroleptic dosing in the treatment of psychosis, there continue to be patients who are administered doses that are higher than recommended. Thirty-six acutely psychotic patients receiving parenteral haloperidol were evaluated by the Brief Psychiatric Rating Scale, the Schedule for Affective Disorders and Schizophrenia-Change Version, and the Nurses' Observation Scale for Inpatient Evaluation, as well as by drug levels in plasma. Patients were compared on the basis of total haloperidol dose in the first 24 hours: regular dose (RD: 10-30 mg) and high dose (HD: 40-80 mg). At baseline, patients in the HD group scored significantly higher on the Brief Psychiatric Rating Scale factor Hostile-Suspiciousness and the Nurses' Observation Scale for Inpatient Evaluation factor Irritability. Assignment to regular-dose and HD groups could not be accounted for on the basis of age, gender, weight, or duration of illness. Moreover, drug levels in plasma indicated that the HD patients did not require higher doses on the basis of differences in haloperidol levels.

Brain lithium concentrations measured with lithium-7 magnetic resonance spectroscopy in patients with affective disorders: relationship to erythrocyte and serum concentrations

Brain lithium concentrations were measured in eight patients with affective disorders using lithium-7 magnetic resonance spectroscopy (MRS). Brain lithium concentrations correlated better with serum concentrations (n = 23, r = 0.66, p < 0.001) than with erythrocyte concentrations (r = 0.44, p < 0.05). Because of previous data in animal experiments these results were unexpected, but the differences in cation transport mechanisms between neurons and erythrocytes may account for the results.

[Comparative research on some clinical and psychopharmacological parameters of reactive paranoid psychoses]

10 patients suffering from reactive psychoses were treated in a standardized manner with pernazine. The dynamic of the clinical picture as well as the behaviour of prolactin levels and the activity of DBH in blood plasma were assessed.

Gonadotropin-associated psychosis in perimenstrual behavior disorder

Sexually provocative and violent behavior have been reported as a result of excess androgens. We now report a temporal relationship between increased gonadotropin levels and behavioral changes in two adolescent girls who presented with a history of aggressive and bizarre sexual behavior coincident with the onset of menarche. We evaluated the possibility of a cyclical hormonal cause with daily measurements of gonadotropins, androgens and estradiol levels and correlated the results with periodic reports on the girls' behavior. We concluded that a correlation exists between periods of extremely violent and sexually provocative behavior and peaks of gonadotropin hormone secretion, even though androgen levels were normal. Treatment with medroxyprogesterone acetate (Depo-Provera) in one case and with leuprolide acetate (Lupron-Depot) in the other suppressed gonadotropin levels, and behavior improved markedly. Thus, the behavioral changes (or psychosis) seen in these girls might have been induced by increased levels of gonadotropins.

Lithium in combination with perphenazine: effect on plasma monoamine metabolites

The addition of lithium to perphenazine altered the pattern of plasma homovanillic acid (HVA) during the course of treatment for acute psychosis. In the perphenazine-treated group plasma HVA declined significantly by days 7-9 of treatment, whereas in the perphenazine-plus-lithium group plasma HVA tended to increase. The pattern for plasma methoxyhydroxyphenethyl-glycol (MHPG) was not significantly different for the two groups. The addition of lithium to a neuroleptic may enhance the metabolism of dopamine.

Thyroid abnormalities during chronic lithium treatment in Hong Kong Chinese: a controlled study

Fifty Chinese psychiatric patients on chronic lithium treatment and the same number of sex- and age-matched control outpatients were assessed by a thyroidologist and underwent laboratory investigations. Lithium patients had a higher rate of goitres (50% vs 10%, P < 0.0001) and a higher mean TSH level (P < 0.005) than controls. Thyroid antibodies were detected in 7 older manic-depressive patients as opposed to 1 control, but not in patients with recurrent unipolar mania. Five patients, but no controls, had single or multiple episodes of hyperthyroidism, which was followed in 2 of them by biochemical hypothyroidism. It is suggested that variations in iodine status, dietary goitrogens, immunogenetic makeup and their complex interactions with chronic lithium treatment may contribute to ethnically different patterns of thyroid abnormalities.

Chromosomal aberrations in a patient with severe psychopathology

The case of a female patient showing aggressive, compulsive, destructive behaviour, ritualistic faecal smearing, and hyperactivity is presented. The behaviour is long standing, therapy-resistant, and its aetiology is unknown, although it is seemingly associated with chromosomal abnormalities secondary to abnormal plasma factors.

Knowledge and compliance towards lithium therapy among Chinese psychiatric patients in Hong Kong

Although patient education is believed to promote medication compliance, the exact relationship between the acquisition of drug knowledge and compliance during lithium treatment is unclear. A survey of 50 Chinese patients on maintenance lithium therapy revealed that their medical knowledge about lithium treatment, as measured by a "Lithium Questionnaire," was very limited. Nonetheless, 70% of these patients were found, by multiple criteria, to be good compliers, and lithium compliance was apparently not affected by the amount of drug knowledge that patients possessed. It is argued that in the process of conducting patient education to enhance lithium compliance, a sound therapeutic alliance is more important than sheer knowledge acquisition.

The first lithium clinic in Hong Kong: a Chinese profile

A study of 50 Chinese patients referred to the first lithium clinic in Hong Kong revealed a high prevalence of recurrent mania and rarely unipolar depression. A history of delusions and hallucinations, and re-diagnosis from schizophrenia to manic depressive psychosis, were common. Lithium was prescribed after 3.9 episodes of illness, and at a dosage of 1,191 mg despite a moderate serum level of 0.63 mmol/l. Laboratory monitoring was haphazard, and polypharmacy was common. This might pose unnecessary risks to some patients.

Hypothalamic-pituitary-adrenal axis hyperactivity and psychosis: recovery during an 8-year follow-up

OBJECTIVE

An earlier study showed that the results of dexamethasone suppression test (DST) predicted outcome among patients with a functional psychosis followed to 1 year. The present study was undertaken to replicate these findings with a different patient group and a longer follow-up.

METHOD

Ninety-two inpatients with nonorganic, nonmanic psychoses had DSTs during their hospitalizations. Raters who were blind to DST results, and to baseline chart or research diagnoses, conducted personal interviews with 71 of the patients 8 years later.

RESULTS

Patients who had been nonsuppressors on the DST were five times more likely than those who had been suppressors to be free of psychotic features and to exhibit insight at the follow-up interview (42% versus 8%). Prognostic differences between these groups were clear within the first year of follow-up. Baseline diagnoses also strongly predicted outcome, even among DST nonsuppressors, and DST results had no prognostic significance among patients with a baseline diagnosis of schizophrenia. Later ages at onset and short episode durations at intake also predicted recovery, but baseline DST suppressor status remained important after control for these factors.

CONCLUSIONS

The findings of this study and those of the earlier follow-up suggest that among patients with a functional psychosis, nonsuppression on the DST is prognostically important, particularly after the exclusion of those who meet narrow criteria for schizophrenia.

Increased concentrations of phosphatidylinositol (PI) and decreased esterification of arachidonic acid into phospholipids in platelets from patients with schizoaffective disorders or atypic phasic psychoses

The concentration of various phospholipids (PLs) and sphingomyelin in platelets and the amount of [14C] arachidonic acid ([14C]-AA) esterified in phosphatidylinositol (PI), phosphatidylserine (PS), phosphatidylethanolamine (PE), and phosphatidylcholine (PC) were measured. The platelet-rich plasmas from unmedicated patients with psychiatric disorders and healthy controls were incubated for 30 min with 1 microM [14C]-AA. Platelets from patients with a schizoaffective disorder according to RDC criteria, a schizophreniform disorder (DSM III criteria) or an atypical phasic psychosis according to FC criteria contained twice as much PI and had significantly increased concentrations of PC as compared to controls (p less than 0.05, t-test). A highly significant (40-70%) reduced rate of esterification of [14C]-AA into PI/PS, PC and PE was found in platelets from patients with schizophreniform, schizoaffective and major depressive disorders but not in platelets from patients with chronic schizophrenia. The largest reduced esterification of [14C]-AA (about 70%) was found in PI/PS of platelets from patients with schizoaffective disorders (1.9 +/- 0.7 vs 6.3 +/- 1.7 mumol [14C]-AA/mol PI/PS; p less than 10(-4), t-test). The results indicate that changes in the metabolism of arachidonic acid and phosphatidylinositol and, to a lesser degree, of phosphatidylcholine in platelets are characteristic of patients with a likely favorable outcome of a psychotic episode.